Impact of the Economic Downturn and Welfare Reforms on Mental Health and Wellbeing in Hackney

Assessing the likely impact and developing mitigating actions

1. Introduction 1.1 In July 2012 the Shadow Health and Wellbeing (SHWb) Board agreed upon four key priority areas within the Health and Wellbeing Strategy. In response to this, a Task and Finish Group was established to identify the additional impetus that the Board could bring to Priority 3:

To promote mental health, focussing on relieving depression and anxiety for working age adults.

- A Task and Finish Group was set up which has met 3 times to develop the scope; the evidence base and to develop a set of recommendations for the SHWb Board to consider at the end of October 2012 (see appendix 1:- Terms of Reference of the group)
- The key focus of the direction given by the Board in relation to each priority area was that it wanted to consider recommendations that added additionality rather than endorse existing work or initiatives to enable its role as influencer of policy across the system; focusing on where the Board can bring additional focus and leadership
- With this in mind, the members of the T & F group felt that the scope of the work for this specific priority area ought to focus on the economic downturn and welfare reforms on the mental health and well being of residents in Hackney. The group determined that rising unemployment, poorer working conditions, depressed incomes and an inability to pay for decent housing and basic needs will all impact on mental and physical health outcomes across all populations in Hackney, but more particularly for more vulnerable groups.
- The group used the Marmot report:- ‘The Impact of the economic downturn and policy changes on health inequalities in London’ as a framework in reviewing the evidence and likely effect of selected social determinants on mental health outcomes in Hackney such as unemployment rise; a drop in ‘discretionary incomes’ of households as a result of benefit changes, wage freezes, pension changes and rising fuel and food prices; lack of decent affordable housing.
- Finally, the group identified, from the evidence review, actions that might be taken by the SHWb Board and other partners in the borough to mitigate this impact on the mental health and wellbeing of residents in Hackney

2. The Marmot Framework – The T & F group worked with key partners to develop proposals based on a full understanding of need supported by evidence and, in particular, an understanding of the anticipated socio-economic consequences of the financial crisis. The Marmot Review identifies key areas that will contribute to poor mental health and the actions required to mitigate the anticipated impact of the economic downturn such as cross sector working and effective measurement and monitoring. The diagram below shows potential consequences, specific actions and the information required to provide an evidence base for the proposals which the group took into consideration as evidenced later in the report:- Figure 1

**MARMOT REPORT**

**Impact of economic downturn on health inequalities:** Poverty, worklessness, poor housing and homelessness, overcrowding, fuel poverty

**Increase in suicides and attempted suicides**

**Possible Negative L/T Health effects**

**Increase in homicides and domestic violence**

**Increase in suicides and attempted suicides**

**MARMOT REPORT**

**Actions to mitigate**

1. Local measurement and monitoring
2. Cross sector working
3. Ensure sufficient incomes
4. Sufficient and affordable housing
5. Reduce fuel poverty
6. Adequate supply of information
7. Commission Specific services

**EVIDENCE OF IMPACT IN HACKNEY**

A. Hackney figure from Welfare Reforms Assessment Project B. % of Households in Hackney living below acceptable minimum income C. Check Domestic Violence Figures (also factor in DV caused by young people being perpetrators to their parents) D. Check Proxy figures: Increased prescriptions for anti-depressant drugs Smoking IAPT figures / stats Statistics for Voluntary Sector groups E. Unemployment Figures F. Homelessness Statistics

**Recommendation for the Board**

1. Appoint an elected member as mental health champion with a brief that includes supporting the development of a mental health/wellbeing ‘charter’ based on the Time to Change pledge.
2. Drive the development of more robust partnerships with JobCentre Plus and other work programme providers including increasing apprenticeships for those with mental health needs.
3. Support wider investment in mental health first-aid training to ensure it is extended beyond the mental health system.

**Recommendation for the Board**

5. Develop and monitor a performance framework of key determinants and KPIs.

**Action for PH and MH Commissioners**

5. More focus on investment in debt advice, cheaper loans (credit unions) and ensure wider promotion and distribution

**Action for PH and MH Commissioners**

4. Produce a Comprehensive Mental Health Assessment

**Action for PH and MH Commissioners**

6. More focus on investment in debt advice, cheaper loans (credit unions) and ensure wider promotion and distribution

**Action for PH and MH Commissioners**

5. Develop and monitor a performance framework of key determinants and KPIs.
6. The London Picture.

The Group considered a large body of evidence of the negative relationship between loss of income, income inequalities, unemployment, fuel poverty and housing issues and health and wellbeing. Independent analyses included in the Marmot report suggests that these socio-economic consequences of the financial crisis will disproportionately affect London due to demographics, higher living costs and the nature of its housing and employment markets (London Health Inequalities Network 2011). For example, the following commentators have said:

- **London Councils** - London will contribute 68% of Local Housing Allowance (LHA) savings, despite accounting for only 16.9% of the sector nationally; 82,000 London households are at risk;

- **Greater London Authority** - Number of homeless households and households placed in temporary accommodation across London could increase by 4,865 by March 2012;

- **National Housing Federation** - 114,000 London households (71%) may be forced to seek cheaper accommodation elsewhere;

- **Institute of Fiscal Studies / New Policy Institute** - Tax and benefit changes on Londoners, amounting to 5.7% of net income for poorest fifth and 1.7% for richest fifth;

- **Job Centre Plus** - 175,000 of Londoners are likely to be reassessed as ‘fit to work’, with 135,000 moving to Employment Support Allowance and 40,000 to Job Seekers Allowance;

- **Work Foundation** - Migration of unemployed young people to London is predicted from areas of the UK more dependent on public sector employment; and

- **London Voluntary Services Council** - More people are in debt arrears in London than any other region and youth unemployment is higher in London than the rest of the UK. 81% of London voluntary services are reporting increased demand on their services at the same time as 54% expect to have to close services.

- The health impact predicted by, for example reduced income and income inequalities are poorer health outcomes (Muennig, 2008, Benzeval et al. 2000) including an increased risk of anxiety, mood or substance use disorders (Sareen et al. 2011). A consequence of increased numbers of people with reduced discretionary income in Hackney will inevitably mean more people in debt or in fear of debt, which in turn is likely to be associated with depression independently of job insecurity (Meltzer et al. 2010). Additionally, there is likely to be an increase in both onset and duration of episodes of common mental disorders as levels of financial stress increase (Welch et al. 2008).

- Three in five people seeking debt advice reported having received treatment, medication or counselling as a result of debt related health problems (London Health Forum). Others found that 91% of people with personal debt reported deterioration in their mental health, notably through stress and depression (Meltzer et al. 2010). There is a strong negative correlation between healthy lifestyles and deprivation. As a result of the changes to income there is expected to see increasing levels of alcohol misuse and smoking, and decreasing levels of physical activity.

4. The Hackney Picture

4.1 This section builds on the evidence from the previous section and summarises the health impact that the financial crisis has had and is likely to have in Hackney through:

a) Describing the changes that have already happened in Hackney and those that are likely to result in the areas of employment, income, and housing;

b) Understanding the extent of the health impact on the general population of Hackney in relation to those areas, including identifying which population groups are likely to be most affected and the scale of the risk (a cumulative impact is expected for some groups);

c) Providing an analysis which can be used to inform strategic planning for mitigation of the impact (which are presented to the Board as recommendations in section 6 of this report).

4.2 The following tables in appendix 2 illustrate the likely numbers in Hackney’s population that will be impacted by and the associated health impacts as a result of:

- Unemployment and the reform of employment related benefits
- Welfare Reforms that are likely to affect household income and associated impacts on health (e.g. fuel poverty)
- Homelessness

5. Analysis of the evidence base in Hackney and the likely associated health impacts

5.1 Unemployment

The impact on health associated with unemployment is likely to be high in Hackney, due to the high and rising levels of unemployment. Since 2004, the average unemployment rate in Hackney has been around 11%. This is anywhere from 2 – 4% higher than the London average. Although the impact will be on the general population, some groups will be affected more than others. Adults over 25 claiming Job Seekers Allowance for over 12 months who are the 2nd highest population on benefit after IB/ESA claimants will also be most affected. In Hackney, Populations with high rates of JSA claimants include:

- Women from black and mixed (black/white Caribbean) ethnic groups aged 45-54

- Men from black and mixed (black/white Caribbean) ethnic groups aged 35-54

- Young people aged 18-24 especially those from mixed (black/white Caribbean) ethnic groups.

- **Health warning 1**: Various studies have found that increased levels of unemployment are associated with increased suicide rates (Giuntoli 2011, Stuckler et al. 2009, Kentikelis et al. 2011). The suicide rate in Hackney has been high between 2008 and 2010, and in 2010 there were nearly 10 suicides per 100,000 population – more than twice the rate for London as a whole. Local audits show that people who commit suicide have no record of contact with mental health services. The suicide rate, however, is not the only indicator of mental health problems. Research has suggested that 26.4% of unemployed people report poor mental health, compared with 13.6% of employed people (Artazcoz et al. 2004).

- **Health warning 2**: Involuntary redundancies in Hackney are likely to lead to high levels of depression even three months following the redundancy, when employment has been secured (Waters 2007). Major impacts on mental wellbeing are likely, including financial strain due to income loss, loss of daily structure and social role, and feelings of frustration and stigma (Giuntoli 2011).

- **Health Warning 3**: Twice as many unemployed people are at risk of domestic violence compared with employed people (Macmillan et al. 2005).

- **Health Warning 4**: Anecdotally, Hackney GPs have already noticed an increasing number of consultations for depression and anxiety, which reflect study findings of increases in both major and minor illnesses among patients dated from when redundancies were first announced, before people actually became unemployed (Quick and Wilkinson 1991).

- **See also Appendix 3** – Simplified cognitive model of unemployment – CBT perspective) which illustrates the psychological impacts of unemployment and possible negative consequences. 5.2 Reform of employment related benefits/housing related benefits leading to reduced disposable income, fuel poverty and impact on health

Many elements of the changes to the welfare system will mean that many households will be financially worse off and will need to live on lower income. The proportion of Hackney residents receiving out of work benefits and means tested benefits is relatively large which will mean that the impact upon residents, the borough and Council and health services will be greater than other local authorities. Considerable work has been undertaken in the Council to understand the issues and impact of the welfare reforms on the residents of Hackney. Some of the findings so far are listed below:-

- In terms of the Housing Benefit Cap and Local Housing allowances changes:-

  - In Hackney 2,800 households affected by Local Housing Allowance (LHA) /Housing Benefit (HB) reform have children (60%) and the Local Authority would have a duty to house them should they become homeless
  - Around 5,000 households in the Private Rental Sector will be affected adversely;
  - 1500 households adversely affected by benefit cap;
  - Over 3,000 of underoccupiers affected;
  - 1250 lone parents known to be adversely affected
  - 27,700 working age claimants affected by changes to Council Tax Benefit;
  - 11,000 affected by DLA changes;
  - There are 8,400 Incapacity Benefit Claimants in Hackney and a number of these could be adversely impacted upon by the new objective assessments for all claimants (over a half of Incapacity Benefits in Hackney suffer with Mental Health related issues).

- The cumulative impact of the various welfare reforms on Hackney residents could be as follows:-

  - **Health Warning 1:-** Fuel poverty and inadequate nutrition, particularly for children, are predicted in Hackney, on account of the increase in the number of households living in unaffordable housing, especially when they spend more than half of their incomes on housing (Guzman et al. 2005).
  - **Health Warning 2:-** Hackney men and women, who are heads of households, may have poorer mental well being associated with unsustainable housing commitments (Taylor et al. 2007).
  - **Health Warning 3:-** Some Hackney residents may be forced to move within Hackney to find affordable housing and it is also likely that people will move out of Hackney to other parts of London where house values are less and housing more affordable. This predicts an increased risk of early death with the loss of social support networks (Berkman and Syme 1979). Moreover those children having to move three times before they are seven years old will be at increased risk of depression (Gilman et al. 2003).

- **Health Warning 4:** Poor physical and mental health is predicted from more Hackney residents living in inadequate quality and insecure housing (Marmot 2010). Children, people with physical disabilities and those aged over 75 are more likely to be affected (Power et al. 2009; DH 2007).

- **Health Warning 5:** The number of children living in poor quality housing will increase and therefore more of Hackney’s children will be at greater risk of suffering anxiety and depression, respiratory and other long-term health problems, and poor mental and physical development (Harker 2006).

- **Health Warning 6:** There is likely to be an increase in asthma and respiratory problems among Hackney children associated with increasing numbers living in cold, damp housing (Barnes et al. 2008, Wilkinson 1999).

- **Health Warning 7:** Poor mental health will increase in Hackney. More children and adults will be at increased risk of anxiety and depression and children, particularly, are likely to suffer from reduced motivation and increased psychological symptoms, independently of household income (Evans et al. 2001).

- **Health Warning 8:** There is likely to be an increase in excess winter deaths (EWD) in Hackney (Hills 2011), caused primarily by respiratory (40%) and circulatory diseases (33%) due to cold homes in cold weather (Power et al. 2009; DH 2007), especially among people over 75 years old (El-Ansari and El-Simily 2008; Woodhouse et al. 1993).

- **Health Warning 9:** There is likely to be an increase in the spread of infectious diseases, in Hackney, such as tuberculosis. This will be on account of disruption to care pathways such that pole do not complete their course of treatment (e.g. they may move on) and increasing numbers of people living in substandard accommodation (lacking efficient heating, adequate hot water supply, and adequate facilities for food storage and waste disposal) and temporary and overcrowded accommodation.

- **Health Warning 10:** Poorer health outcomes will also result in Hackney as a result of increases in homelessness. There will be increasing numbers of children with physical and mental health problems, including, depression, behavioural problems and severe academic delay (Guzman 2005). Homeless adults living in Hackney will be more likely to die, especially those living rough (who already have a very low life expectancy of 42 years). Staying in hostels, overcrowded, temporary or substandard accommodation will lead to common health problems include respiratory conditions, foot conditions and dental problems, as well as mental health problems.

6. Summary of key messages from the analysis above

- Some health impacts only arise in association with one social determinant and others are linked to several determinants, which may themselves be interlinked. This means that the impact on the mental health of Hackney residents is predicted to be particularly large as income, employment and housing all have a significant association with mental health.

- Moreover, some groups of Hackney residents will be disproportionately affected by the changes. The health of children, for example, is likely to be particularly severely affected because of the associations with income, employment and housing changes. Young men, in particular young black men, are disproportionately affected by unemployment, which is likely to be associated with significant mental health problems, including increased suicides.

- Some groups of people will be less resilient to the changes and reductions in income than others if they have fewer social support networks or are more vulnerable and are less able to cope with change (for example older people and people with disabilities).

- The Task and Finish Group identified 6 key actions to mitigate the impact of the economic downturn and the welfare reforms on the residents of Hackney that needed to be taken forward in the short and medium term. Three of the recommendations are recommended for the Board to sponsor (detailed in section 7 below) and three of which will be taken forward by Mental Health and Public Health Commissioners (detailed in section 8 below). Once approved, these recommendations will be looked into more detail and an Action Plan with timeframes for implementation, resource implications and key leads for delivery will be presented to the next Shadow HWB.

7. Mitigating the Impacts – Key Recommendations for the SHWb Board to consider and endorse:

7.1 Appoint an elected Member as ‘Mental Health Champion’ with a brief that includes supporting the development of a local mental wellbeing/promotion ‘charter’ based on the national ‘Time to Change’ pledge and encouraging the adoption of the “Time to Change” pledge across the HWB partnership • As the shadow HWB board, pledging to support the national “Time to Change” campaign is a public display of the partnership’s commitment to ending mental health discrimination. It also directly addresses the issue of the stigma experienced by people with histories of depression highlighted in the findings of the international study recently reported in *The Lancet*.

• This role might include raising awareness of mental health issues, including the impact of stigma and discrimination, across the full range of the work of the shadow HWB Board and with other elected members including lead members for children. This Member could also to champion the delivery of a suicide prevention and mental health promotion strategy.

______________________________________________________________________

**Example: Member champions for mental health**

In 2010, Dorset County Councillor Michael Bevan became the council’s member champion for mental health. Cllr Bevan’s role is to raise awareness of mental health issues in all areas of the authority’s business and to improve links between the council and local health services. He works closely with local employers and with the Time to Change programme to tackle stigma and improve public understanding about mental health. He brought together around 140 local organisations to agree shared actions to improve mental health and the lives of people affected by mental illness in the county.

______________________________________________________________________

7.2 Strengthen partnerships with JobCentre plus and work programme providers to promote supported employment initiatives, learning from the experience and expertise of initiatives such as the Rose Programme and the Hackney Community College Mental Health, Education and Employment Project.

• Improve pathways into employment within services for "Experts by Experience" as Health Guides, Benefits Advisors, Mental Health First Aid Trainers and Advocates.

• Include the Human Resources Divisions of all key partners in action to identify opportunities for supported employment within their organisations. Promote supported employment among key suppliers and contractors including Supported Housing Providers.

• In addition develop partnerships with and between businesses and voluntary sector agencies in both Hackney and the City of London to identify opportunities for apprenticeships within Hackney’s expanding arts, creative, fashion and media industries. Align this work with the Council’s Economic Development Strategy and the work of the Hackney Strategic Partnership.

7.3 Ensure mental health first aid training is extended beyond the mental health system:- By commissioning and rolling out the nationally accredited Mental Health First Aid Lite Course ("MHFA lite") which is a 3-hour MH awareness training course for key staff/workforce across health partners; the Council and other public sector partners such as the Police and Housing Associations, prioritising those staff who have ‘first contact’ with service users and customers

8. Mitigating the Impacts – Key Recommendations that will be taken forward by Mental Health and Public Health Commissioners

8.1 Ensure local mental health needs are comprehensively assessed, and ensure they are given appropriate weight in comparison with physical health needs

A comprehensive assessment of mental health needs and services in Hackney would assist in identifying whether local commissioners of services that address mental health and wellbeing (including CCG, social care, public health) are investing in services with the greatest capacity to prevent mental distress, improve mental health outcomes and enable people to achieve their goals through recovery. This assessment would go beyond the health and wellbeing profile, looking across the prevention-recovery pathway and encompassing an assessment of the effectiveness, humanity, equity and costs of services. As such it would support the development of local services in the new policy environment.

8.2 Coordinate the development of a local measurement and monitoring framework across a range of determinants. A challenge persists as the consequences of the recession, welfare reform and changes to public services take effect. It is therefore imperative to monitor if predicted local housing, employment, income and health outcomes become reality and whether sufficient preventative services are in place.

Hackney Council and health service commissioners need to monitor changes in housing, employment, income and demographics in the coming years, as well as their known health effects on mental health wellbeing in order to:-

- Plan services for mental health across education, primary care; social care and public health programmes
- Maintain delivery of statutory duties (e.g. child and adult safeguarding);
- Identify groups or individuals that may be specifically adversely affected by the changes (e.g. homeless; young black men; lone parents);
- Support statutory health and equalities impact assessments of service reconfiguration; and Facilitate collaboration and negotiation between boroughs and with national Government (including supporting bids for ‘discretionary funding’).

The Council has already developed a Welfare Reform Working Group monitoring dashboard which can be built upon to include other relevant measures from the Public Health Outcomes Framework (an example set of indicators are given in Appendix 4 of this report). Commissioners will develop an action plan on how these indicators can be factored into service planning and service delivery across key partnership agencies.

8.3 Ensure sufficient provision of advice and information services to cope with likely issues:-

- Ensure that information regarding debt advice, finance, budgeting and managing credit is widely and effectively distributed at all Council Services delivery points.
- Ensure access to appropriate banking and credit facilities is included in all Assessment and Care Planning processes across the Mental Health sector, including within East London Foundation Trust, within supported housing and temporary housing settings, and within the Hackney Community College Mental Health, Education and Employment Project.
- Actively promote Credit Union membership at all Council Services delivery points including libraries and cultural and leisure facilities, and utilising the Council’s communications resources including Hackney Today and the Council’s website.
- Commission the ‘mental health network’ model which will ensure a coordinated approach to information, advice, advocacy, prevention, social inclusion and recovery for people with mental health needs including the alignment of the IAPTs service.

References

Artazcoz L, Benach J Borrell C, Cortès I, Unemployment and Mental Health: Understanding the Interactions Among Gender, Family Roles, and Social Class, American Journal of Public Health | January 2004, Vol 94, No. 1, 82-88, 2004

Baker W. (2011) Fuel price inflation and low income consumers. London: Consumer Focus. www.consumerfocus.org.uk.

Barnes M, Butt S, and Tomaszewski W (2008) The Dynamics of Bad Housing: The Impact of Bad Housing on the Living Standards of Children. London: National Centre for Social Research.

Benzeval M, Taylor J and Judge K. (2000) Evidence on the Relationship between Low Income and Poor Health: Is the Government Doing Enough? Fiscal Studies, 21(3):375–99. El-Ansari W and El-Silimy S (2008) Are fuel poverty reduction schemes associated with decreased excess winter mortality in elders? A case study from London, UK. *Chronic Illness*, 4(4): 289–94.

Gilman SE, Kawachi I, Fitzmaurice GM, Buka SL. (2003) Socio-economic status, family disruption and residential stability in childhood: relation to onset, recurrence and remission of major depression. *Psychol Med*, 33:1341-55.

Giuntoli G, South J, Kinsella K and Karban K. (2011) *Mental health, resilience and the recession in Bradford*. York: Joseph Rowntree Foundation. http://www.jrf.org.uk/sites/files/jrf/unemployment-mental-health-full.pdf

Goldberg DP, Williams P, the user’s guide to the general health questionnaire, Nfer-Nelson, 1988.

Guzman C, Bhatia R and Durazo C. (2005) Anticipated Effects of Residential Displacement on Health: Results from Qualitative Research. San Francisco, CA: Department of Public Health. http://www.sfphes.org/publications/reports/Trinity_Focus_Groups.pdf

Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D, Health effects of financial crisis: omens of a Greek tragedy, www.thelancet.com Published online October 10, 2011 DOI:10.1016/S0140-6736(11)61556-0, 2011

Macmillan R, Kruttschnitt C, Patterns of Violence Against Women: Risk Factors and Consequences, National Institute of Justice Grant # 2002-IJCX-0011, Final Report, 2005

Marmot Review Team (2010) *Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010* (The Marmot Review). London: Marmot Review.

Marmot Review Team (2011) The Health Impacts of Cold Homes and Fuel Poverty. London: Friends of the Earth and Marmot Review Team. www.foe.co.uk/resource/reports/cold_homes_health.pdf

Meltzer H, Bebbington P, Brugha T, Jenkins R, McManus S and Stansfield S. (2010) Job insecurity, socio-economic circumstances and depression. *Psychological Medicine*, 40;1401-7.

Montgomery SM, Cook DG, Bartley M, et al. Unemployment pre-dates symptoms of depression and anxiety resulting in medical consultation in young men. *Int J Epidemiol* 1999;28:95e100., 1999

Muennig P, Health Selection vs. Causation in the Income Gradient: What Can We Learn from Graphical Trends?, *Journal of Health Care for the Poor and Underserved* 19 (2008): 574–579, 2008

Power A, Davis J, Plant P and Kjellstrom T. (2009) *The built environment and health inequalities*. Task group submission to the Marmot Review. Quick A, Wilkinson RG, Income and Health, Socialist Health Association, 1991. ISBN 0900687177

Sareen J, Afifi T, McMillan K and Asmundson G. (2011) Relationship between household income and mental disorders: Findings from a population-based longitudinal study. Arch Gen Psychiatry, 68(4):419-27.

Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M, The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis, www.thelancet.com Vol 374 July 25, 2009

Taylor M, Pevalin D and Todd J. (2007) The psychological costs of unsustainable housing commitments. Psychological Medicine, 377(7):1027-36.

Welch S, Lewis G, Poverty, unemployment, and common mental disorders: population based cohort study, BMJ 317, 11 July 1988, 115-119, 1988

Wilkinson D, Poor Housing And Ill Health A Summary Of Research Evidence, Scottish Office, 1999

Woodhouse PR, Khaw KT and Plummer M (1993) Seasonal variation of blood pressure and its relationship to ambient temperature in an elderly population. Journal of Hypertension, 11(11):1267–74.

Bibliography

Assessing the Impact of the Financial Crisis on Health and Wellbeing in Lewisham (Lewisham Annual Public Health Report 2011-2)

Health & Wellbeing Strategy for Hackney: Proposals for the Shadow Health & Wellbeing Board (2012)

No Health Without Mental Health: Implementation Framework (DH 2012)

Fair Society, Health Lives (The Marmot Review 2010)

Community Mental Health Services (Health in Hackney Scrutiny Commission 2012)

Mental Health Commissioning Ambitions (City & Hackney CCG 2012)

Promoting Mental Well-Being in Newham (NHS NELC, Newham Council 2012)

Preventing Suicide in England: A Cross-Government Outcomes Strategy (DH 2012)

Mental Health and the Productivity Challenge (The Kings Fund 2010) Data and other relevant information that has been used to inform the scope include:

- City & Hackney Joint Strategic Needs Assessment 2011-2 (JSNA)
- IAPT in Inner North East London (London Health Programmes)
- Mental Health Third Sector activity and performance data
- IAPT activity and performance data
- Anti-depressant prescribing data 2009-10
- Commissioning Outcomes Framework 2012 (COF)
- City & Hackney Severe Mental Illness (SMI) register

Appendices:

Appendix 1:- ToR – T & F Group Appendix 2:- Tables illustrating impact of welfare reforms on health and wellbeing in Hackney Appendix 3:- Simplified cognitive model of unemployment – CBT perspective Appendix 4:- Hackney Welfare Reform Working Group Monitoring Dashboard Appendix 5:- Draft set of additional recommended indicators to measure impact of recession and welfare reforms on health and wellbeing Appendix 6:- ‘Time to Change’ pledge and case studies 1.0 Purpose

In response to the recommendations made by the Shadow Health & Wellbeing Board to establish a Mental Health Task and Finish Group in accordance with the strategic direction set out in the Health & Wellbeing Strategy for Hackney, specifically:

- To promote mental health, focusing on relieving depression and anxiety for working age adults.

2.0 Objectives

- In accordance with the recommendations of the Marmot Team to provide a clear steer as to how services will improve the life chances of local people as a means to secure sustainable improvements;
- To identify resources to change the ways in which services are currently delivered to ensure improvements are secured for the mental wellbeing of Hackney residents;
- To propose how to work with local people to fully understand how best they can take responsibility for promoting positive mental health. Central to this will be a renewed commitment to developing communities to be active in securing better outcomes.
- To propose new models of commissioning to meet unmet needs and explore the potential of integration of services as a means of improving health and wellbeing and reducing unnecessary duplication.

3.0 Tasks

- To convene a Task and Finish Group, made up of colleagues from relevant organisations and sectors. It is emphasised that the purpose of the Group is to work swiftly and effectively and focus on the task in hand.
- Map what is already provided locally and identify gaps and duplications. • Consider where best the Health & Wellbeing Board might intervene and how it should do so.

• Define pieces of work that the Health & Wellbeing Board can sponsor which will enhance the work already undertaken.

• Ensure additionality so that the Health & Wellbeing Board will be able to focus on areas where it has the ambition and ability to add value by working in partnership across the membership organisations to improve health and wellbeing. It is not proposed, however, that work is duplicated in Hackney or the responsibilities of others is taken on.

• Bring worked up proposals to the Health & Wellbeing Board in October.

• Demonstrate how proposals have been formulated and, where relevant, proposals to be costed with clear indications about how the costs could be met.

4.0 Membership

Service user (TBC) Voluntary sector representative (TBC) Elected member representative (TBC) David Maher - CCG MH programme director Rhiannon England - CCG GP Amanda Douglas – PCT/LBH Public Health Strategist Pratima Solanki - LBH Assistant Director of Commissioning (Chair) Stephen Hardisty - Joint Mental Health Commissioner Brian Innis - LBH Contracts & Commissioning Manager

5.0 Frequency of Meetings

Monthly meetings.

6.0 Accountability

To be accountable and provide regular progress reports to the Health & Wellbeing Board.

7.0 Review

The work of the Mental Health Task & Finish will be short term project that will end in October 2012.

DRAFT v. 1.1 (updated 15 August 2012) Appendix 2: An overview of the predicted health impacts of the recession and welfare reform in Hackney, based on the Lewisham Literature

Table one: Dynamics in the labour market and associated health impacts

| Socio-economic consequences of recession/reform of employment related benefits | Current and expected socio economic changes in Hackney | Estimated numbers or % affected | Health impacts predicted for Hackney | Populations most affected | |---|---|---|---|---| | Unemployment levels remain broadly the same, but the economic climate may have greater impact on some populations | Since 2004, the average unemployment rate in Hackney has been around 11%. This is anywhere from 2-4% higher than the London average. Since 2009, similar to London and the UK, the rate has remained high but relatively stable. See the populations most affected column for details on groups that tend to remain unemployed and on benefit for a longer duration. | 10,800 of Hackney's residents claim Job Seekers Allowance (JSA). | Standard mortality ratio for the unemployed is considerably higher in every social class. Increased mortality and reduced life expectancy. Increased mortality from lung cancer and CVD. Potential increase in suicide rate. There has been a high suicide rate recorded in Hackney for the third year in a row. The suicide rate in Hackney remains unusually high. In each of the three years from 2008 to 2010 between 19 and 22 Hackney residents ended their own lives. The rate in 2010 was nearly 10 suicides per 100,000 | Adults over 25 claiming Job Seekers Allowance for over 12 months are the 2nd highest population on benefit after IB/ESA claimants. Populations with high rates of JSA claimants include: - Black and mixed (black/white Caribbean) race women aged 45-54 - Black and mixed (black/white Caribbean) race men aged 35-54 - Young people aged 18-24 especially mixed (black/white Caribbean) race young people. | | Socio-economic consequences of recession/reform of employment related benefits | Current and expected socio economic changes in Hackney | Estimated numbers or % affected | Health impacts predicted for Hackney | Populations most affected | |---|---|---|---|---| | Numbers on out of work benefits & workless remain broadly the same; Entering the labour market remains challenging for this population | In 2004, 29,310 residents were on key out of work benefits in 2011, this number was 29,750. This represents 22% of the working age population consistently on key benefits (including job seekers allowance, | Increase in common mental health disorders, including, depression & mood and anxiety disorders Increase in smoking prevalence Increase in substance misuse and dependency | Approximately 13,500 people in Hackney claim incapacity benefit or employment and support allowance, this is roughly 9% of the working age population. Of this group: - approximately 8,400 claim for Incapacity Benefit or Severe Disablement Benefit (IB/SD) and - approximately 5,100 people claim Employment | | Socio-economic consequences of recession/reform of employment related benefits | Current and expected socio economic changes in Hackney | Estimated numbers or % affected | Health impacts predicted for Hackney | Populations most affected | |---|---|---|---|---| | Reform of out of work benefits continues and is yet to affect a significant proportion of this population. | ESA and incapacity benefits and lone parent benefits) A steady population of around 13,500 have been on Incapacity Benefit and Employment Support Allowance over the time period, nearly 3% higher than the London rate. | Increase in alcohol related harm. Increased risk of domestic violence. | Support Allowance (ESA). Populations with a higher uptake of IB include: Older men and women: - 22% of men and 14% of women aged 55-64 claim IB. Middle aged and older men and women with mental health problems: - 6% of women aged 45-54 and 8% of men aged 55-64 claim IB due to mental health problems. Middle aged men and women: - 33% of both male and female ESA claimants are aged 45-54 and 25% are aged 35-44. - 7% of all men and women aged 45-54 claim ESA. | Low paid workers | | Low pay | Weekly earnings for residents are increasing but still lower than London | Over half the 105,500 workers in Hackney earn less than the weekly London average. | Poorer health outcomes and self-related health Higher rates of mental health disorders, including, depression & mood and anxiety disorders Higher rates of smoking | Low paid workers | | Socio-economic consequences of recession/reform of employment related benefits | Current and expected socio economic changes in Hackney | Estimated numbers or % affected | Health impacts predicted for Hackney | Populations most affected | |---|---|---|---|---| | Welfare reforms will result in a reduction in benefits and a loss of income for some residents. The details of who we expect to be affected based on analysis of claimant populations are in column 3. | Loss of income for particular benefit recipients. - Some Local Housing Allowance (LHA) claimants in Private Rental Sector (PRS) - Large families particularly affected by benefit cap - Under-occupiers in Social | Around 5,000 affected households in the Private Rental Sector 1500 affected by benefit cap | A reduction in income that results in loss of discretionary income is associated with poorer health outcomes. Higher mortality rates Potential increase in suicide and attempted suicide rates. Poorer child health status | Large Families Young people 25-35 |

Table 2: Welfare reforms likely to affect household income and associated impacts on health | Socio-economic consequences of recession/reform | Current / expected socio economic changes in Hackney | Estimated numbers or % affected | Potential health impacts predicted for Hackney | Populations most affected | |-----------------------------------------------|---------------------------------------------------|---------------------------------|-----------------------------------------------|---------------------------| | Rented Sector | - Young people claiming Housing Benefit for a 1-bed property

- Lone parents affected by changes in income support (entitlement only for children up to age 5, previously age 7)
- Council tax benefit changes
  - Disability Living Allowance (DLA) to Personal Independence
  - Payment (PIP)
  - Reassessment of entitlement for Incapacity Benefit (for details see table 1), continues over the next couple of years, could result in loss of income. | Number of underoccupiers affected over 3,000\
    1250 lone parents known to be affected\
    27,700 working age claimants affected by changes to Council Tax Benefit\
    11,000 affected by DLA changes\
    8,400 Incapacity Benefit Claimants | Poorer health outcomes and self-related health\
    Increase in major and minor illnesses for primary care patients\
    Major impact on people’s mental wellbeing – depression, mental health disorders, including mood & anxiety disorders\
    Potential impact on unhealthy behaviours, including substance misuse and substance use disorders.\
    Increased incidence of coronary heart disease. | Older working age people with children that have left home\
    Lone parents\
    Disabled people and people with and long term health conditions.\
    See table 1 above for a profile of people likely to be more affected by IB reforms. | | Socio-economic consequences of recession/reform | Current / expected socio economic changes in Hackney | Estimated numbers or % affected | Potential health impacts predicted for Hackney | Populations most affected | |------------------------------------------------|---------------------------------------------------|---------------------------------|-----------------------------------------------|--------------------------| | Introduction of Universal Credit likely to mean a decrease in overall benefit levels received by some | 34,000 affected by introduction of UC | | | All claimants |

Table 3 Potential impacts of welfare reform and recession on homelessness and fuel poverty and associated health impacts

| Socio-economic consequences of recession/reform | Current / expected socio economic changes in Hackney | Estimated numbers or % affected | Potential health impacts predicted for Hackney | Populations most affected | |------------------------------------------------|---------------------------------------------------|---------------------------------|-----------------------------------------------|--------------------------| | Reforms to benefit entitlement may lead in some cases to an increased risk of homelessness. There is a greater risk of fuel poverty as a result of welfare reforms/a drop in wages/ rising prices for energy/food. | Potential increase in homelessness and temporary accommodation as a result of welfare reform | 2,800 households affected by Local Housing Allowance (LHA) /Housing Benefit (HB) reform have children (60%) and the Local Authority would have a duty to house them should they become homeless 1,900 of those affected by LHA/HB reform do not have children and therefore may not be eligible for accommodation support from the Local Authority should they become homeless Currently 1,400 households are in temporary | Homelessness contributes to a number of physical, behavioural and mental health problems in adults and children. Reduced life expectancy. Poorer health outcomes and self- related health. Poorer nutrition. Poorer mental wellbeing, increased risk of depression. Increase in onset and duration of mental disorders. | Large families with children Younger, single people | | Socio-economic consequences of recession/reform | Current / expected socio economic changes in Hackney | Estimated numbers or % affected | Potential health impacts predicted for Hackney | Populations most affected | |-----------------------------------------------|---------------------------------------------------|---------------------------------|-----------------------------------------------|---------------------------| | Potential increase in overcrowding and housing in poor quality accommodation, especially for those in the private rented sector claiming Housing Benefit affected by reform | Overcrowding levels currently estimated to affects 9.6% of households (8,899), significantly greater than both the national (2.5%) and London (6.6%) averages. 1300 claimants will see a drop in benefits of over £50 a week which is likely to necessitate a move to smaller accommodation or cheaper accommodation/in a cheaper location | Greater risk of suffering from anxiety and depression. Children living in bad housing are at greater risk of suffering anxiety and depression, respiratory and other long term problems, and poor mental and physical development. Risk of respiratory, asthma and other long-term health problems. Cold housing is a significant risk factor for children developing asthma. | Large families with children Private sector tenants claiming Housing Benefit | | Introduction of Universal Credit paid direct to claimants likely to mean difficulty budgeting for some households, increase in arrears and private landlords looking to avoid housing benefit claimants. | 34,000 affected by introduction of Universal Credit | Increased risk of CVD. Greater risk of poor mental and physical development Risk of increase in infectious disease including TB. Poorer ability to adhere to treatment regimes leading to relapse, reactivation or antibiotic resistance. | All claimants potentially affected | | Those affected by reform and/or drop in income may find themselves affected by fuel poverty | In Hackney, fuel poverty has nearly doubled from 7.6% in 2006 to 13.3% in 2009 Fuel poverty is higher in | Potential increase in domestic violence. | Benefit recipients Those on low incomes, including those with disabilities | | Socio-economic consequences of recession/reform | Current / expected socio economic changes in Hackney | Estimated numbers or % affected | Potential health impacts predicted for Hackney | Populations most affected | |-----------------------------------------------|---------------------------------------------------|---------------------------------|-----------------------------------------------|--------------------------| | | certain parts of Hackney, 14% of the households in the Leabridge ward of Hackney were in fuel poverty in 2010 | On an estimated pro rata basis as many as 20 excess winter deaths in 2008-9 in Hackney could be attributed to cold homes caused by fuel poverty. | Risk of increased in substance misuse and dependency. Risk of increase in excess winter deaths particularly in those over 75 years. Increased risk of premature death. | Older persons 75+ | Appendix 3

Simplified cognitive model of unemployment - CBT perspective Appendix 5:- Draft Set of additional recommended Indicators to measure impact of recession and welfare reforms on health and wellbeing that could be added to Hackney’s Welfare Reform Working Group monitoring dashboard:-

**Socio-economic indicators**

Average earnings

Number of Jobseeker’s Allowance claimants

% Jobseeker’s Allowance claims for more than 6 months

Number of young people (18-24) claiming JSA

Number of people claiming ESA (incapacity benefit)

Number of people seeking debt advice

Number of children receiving free school meals, eligibility and uptake

School readiness measure

Number of people claiming housing benefit

Number of people moving in and out of borough and total population

Broad Rental Market Area values for Hackney (Inner and Outer SE London)

The % of children who worry a lot about money

The % of children who usually get spending money

The % of those who got £5 or less when they were last given spending money

The % of children who have a regular job outside school term-time.

The % of children who worked for money in the week before the survey

**Health & Wellbeing Indicators**

Life expectancy

Mortality rates

Premature mortality for cancer

Premature mortality for CVD

Suicide rate Incidence of tuberculosis

Alcohol related admissions to hospital

Asthma admissions to hospital of children

Reported cases of domestic abuse

Hospital admissions for severe and enduring depression

Prescriptions for anti-depressants

Physical activity levels

Diagnosed prevalence of long term conditions e.g. hypertension, asthma, chronic obstructive pulmonary disease

National Child Measurement Programme (NCMP) in Reception and Year 6 (identifies underweight, overweight and obese)